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Comparison of Defolliculated Oocytes and Intact Follicles of the Cockroach Using the Vibrating Probe to Record Steady Currents
Medical Hypotheses 85 (2015) 79–81
Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Assigning appropriate primary cause of death and indication for medical procedures Nnabuike Chibuoke Ngene a,b,⇑, Jagidesa Moodley c a
Department of Obstetrics and Gynaecology, Edendale Hospital, Pietermaritzburg, South Africa University of KwaZulu-Natal, Durban, South Africa c Women’s Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa b
a r t i c l e
i n f o
Article history: Received 6 March 2015 Accepted 3 April 2015
a b s t r a c t The most appropriate primary cause of death in a patient who had multiple medical conditions is that medical condition which initiated the chain of events that led to the other medical conditions that resulted in death. In clinical practice, there are deceased patients who had several medical conditions that could lead to death (primary causes of death) without biological plausibility that any of the medical conditions initiated the chain of events that resulted in the other medical conditions. To assign the single most appropriate primary cause of death to such a deceased patient is challenging. Under such circumstances, the International classification of diseases and related health problems, tenth revision (ICD-10) guidelines recommend that the medical practitioner certifying the death should decide on the primary cause to be assigned. The ICD-10 also acknowledges that the recommendation is arbitrary. Similar difficulty is also encountered when a single indication is being assigned to a patient for a medical procedure when there are multiple indications for such a procedure. The ICD-10 and its clinical modification (ICD-10-CM) which provides the guidelines for assigning indication for a medical procedure use criteria that are insufficient. In the present article, comprehensive, easy and objective clinicopathological criteria on how to assign the single most appropriate primary cause of death or indication for a medical procedure are recommended. The new criteria (referred to NJ model II) may be used to improve the ICD-10. Ó 2015 Elsevier Ltd. All rights reserved.
Introduction It is challenging to assign one primary cause of death to a deceased patient who had multiple principal diagnoses. Similar difficulty is encountered when a single indication for a medical procedure is being assigned to a patient who has multiple reasons to undergo such a procedure. The International classification of diseases and related health problems, tenth revision (ICD-10) guidelines devised to address these challenges is inadequate [1] and, therefore, needs to be improved. The present article posits novel solutions to these challenges. ICD-10 recommends that if a deceased patient had multiple primary causes of death, the medical condition that could have led to other primary causes of death should be selected when a single most appropriate primary cause of death is to be chosen [1]. However, where the general principle is not applicable, the death certifier (if possible) should provide clarification on what could be selected as the single most appropriate primary cause of death. ⇑ Corresponding author at: P.O. Box 101894, Scottsville, Pietermaritzburg 3209, South Africa. Tel.: +27 83 518 7391; fax: +27 86 613 9560. E-mail address: [email protected] (N.C. Ngene). http://dx.doi.org/10.1016/j.mehy.2015.04.002 0306-9877/Ó 2015 Elsevier Ltd. All rights reserved.
This is because the selection rules are somewhat arbitrary and could lead to an unsatisfactory selection of the underlying cause [1]. The development of novel criteria proposed in the present article is an attempt to resolve this limitation of ICD-10. Furthermore, both ICD-10 and its clinical modification (ICD-10CM) [2] do not provide sufficient guidelines on how to select the single most appropriate indication for a medical procedure when a patient has multiple indications for such a procedure. For instance, the ICD-10-CM recommends that the medical condition chiefly responsible for the therapeutic services being provided to a patient should be selected as the first indication for a medical procedure offered to such a patient [2]. However, the criteria recommended in ICD-10-CM for the selection of the medical condition that is chiefly responsible is subjective [3].
The hypothesis Our hypothesis is that the use of novel criteria (proposed in the present article) to assign the most appropriate single primary cause of death or an indication for medical procedure will yield more reproducible results (primary cause of death/an indication)
80
N.C. Ngene, J. Moodley / Medical Hypotheses 85 (2015) 79–81
than ICD-I0 or ICD-10-CM. The novel criteria are referred to as NJ model II for easy referencing. The criteria in NJ model II are comprehensive and not subjective unlike those of ICD-10 that are occasionally arbitrary/insufficient. NJ model II is an idea that has evolved following the previously published NJ model that entails the use of clinicopathological criteria to assign principal diagnosis [3]. NJ model II 1. Assigning an appropriate primary cause of death: if a patient has multiple primary causes of death and there is no single cause of death/medical condition that possibly could have led to the other primary causes of death, then the medical condition with the highest local case-fatality rate should be selected as the most appropriate primary cause of death. 2. Assigning an appropriate indication for medical procedure: when a patient has indications to undergo a medical procedure, the single most appropriate indication for the medical procedure is that which first satisfies the top-most criteria described below: (a) Absolute indication that occurred first. (b) Absolute indication that prevents the use of other available treatment modality with the best efficacy. This is applicable where multiple absolute indications exist and their order of occurrence is not known. (c) Absolute indication with the highest local case fatality rate. This applies to a situation where the order of occurrence of absolute indications is not known, and the existing indications do not prevent the use of other treatment modality, i.e. does not satisfy criterion 2b. (d) Absolute indication. This is obtainable when there is only a single absolute indication with or without any relative indication. (e) Relative indication that prevents the use of available alternative treatment modality with the best efficacy. This criterion is important where there is no absolute indication but existence of multiple relative indications. Given that relative indication does not mandatorily require that the medical procedure is performed, in authors’ opinion, the order of occurrence of relative indication is not of priority. For instance, in an empirical case report, a primigravida at term was diagnosed with prolonged latent labour after a ruptured membrane. She subsequently developed a suspicious cardiotocography and had a caesarean section (CS). The indication for the CS is fetal compromise and not prolonged latent labour because the suspicious cardiotocography prevented the use of oxytocin for augmentation of labour. Either the prolonged latent labour or suspicious cardiotocography is a relative indication for CS. This case report is described in greater details under empirical data. (f) Relative indication associated with the highest local case fatality rate. Evaluation of the hypothesis The use of simple comprehensive and objective criteria (NJ model II) proposed in the present article will reduce subjectivity, and ensure that a reproducible primary cause of death or indication for a medical procedure is assigned to each patient. This is the strength of NJ model II. It is acknowledged in the ICD-10 that the guidelines on how to assign the most appropriate single primary cause of death prescribed in the ICD-10 are arbitrary [1]. The arbitrary rule may partly explain the 45.5% mean discrepancy rate between the causes of deaths assigned clinically and the histopathological autopsy findings [4]. Although variations have
been noted in autopsy reports, [5] histopathological autopsy, in particular, is considered the gold standard for confirming the cause of death [4]. When two autopsies performed on the same individual shows discrepant reports (primary cause of death), a third autopsy should be considered. If a third autopsy is not possible, NJ model II may be applied and the condition with the highest case fatality rate selected as the most appropriate cause of death. Nonetheless, the difficulty of determining case fatality rates is a limitation that may be associated with the use of NJ model II. In the authors’ opinion, case fatality rate is an objective criterion, and its use is, therefore, appropriate. Causes of death in patients with several medical conditions have been reported in the literature [6–8]. In such reports, the use of case fatality rates, as recommended in NJ model II, may be of value in guiding the selection of the most appropriate cause of death. To test the NJ model II, a cohort of selected patients will be assigned the outcome of interest (primary cause of death or indication for medical procedure) by a group of medical practitioners using ICD-10 guidelines. Another group of medical practitioners will use NJ model II to assign the outcome of interest to the same cohort of patients. The proportions of reproducible outcomes assigned by each group of medical practitioners will show the superiority/inferiority of NJ model to ICD-10. Plans are underway to employ the proposed method to evaluate NJ model II. Empirical data In an empirical case report, a primigravida at term was diagnosed with prolonged latent labour after a ruptured membrane. She subsequently developed a suspicious cardiotocography and had a caesarean section (CS). The patient had no co-morbidity, and both the CS as well as the postpartum period was uncomplicated. The attending medical officer was requested to select an indication for each CS performed in that hospital. While compiling the list of the indications, the same attending medical practitioner selected prolonged latent labour as the indication for the CS performed on the primigravida. The medical practitioner was of the opinion that either fetal compromise or prolonged labour could be selected, that the choice is at the medical practitioner’s discretion. We argue that practitioner’s choice should be guided by criteria that are apt to generating reproducible result. ‘‘Based on NJ model II (criterion 2e), the most appropriate indication for the CS should be fetal compromise and not prolonged latent labour. This is because the suspicious cardiotocography, a possible evidence of fetal compromise, influenced the management decision not to use oxytocin to augment the labour. Fetal scalp pH testing that helps to establish fetal compromise is not recommended in our centre due to high incidence of Human Immunodeficiency Virus infection. Either the prolonged latent labour or suspicious cardiotocography is a relative indication for CS. Consequences of the hypothesis The use of NJ model II will ensure that a reproducible primary cause of death and or indication for a medical procedure is assigned to each patient. The frequency of such primary causes of deaths or indications for medical procedures is of public health importance and may influence health policies. Sources of support in the form of grant None. Conflict of interest statement The authors have no conflicts of interest to declare.
N.C. Ngene, J. Moodley / Medical Hypotheses 85 (2015) 79–81
References [1] World Health Organization. International statistical classification of diseases and related health problems. 10th Revision, vol. 2 instruction manual. 2010 edition. Geneva, Switzerland. Available at:; 2015 [accesses 01.03.15]. [2] Centre for Disease Control. ICD-10-CM official guidelines for coding and reporting 2014. Available at: ; 2015 [accessed 01.03.15]. [3] Ngene NC, Moodley J. Assigning appropriate and comprehensive diagnosis for scientific report. Med Hypotheses 2014;83(6):64–8. [4] Roulson J, Benbow EW, Hasleton PS. Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review. Histopathology 2005;47(6):551–9. [5] Colville-Ebeling B, Freeman M, Banner J, Lynnerup N. Autopsy practice in forensic pathology e evidence-based or experience-based? a review of autopsies
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performed on victims of traumatic asphyxia in a mass disaster. J Forensic Leg Med 2014;22:33–6. [6] Whiteside YO, Selik R, An Q, Huang T, Karch D, Hernandez AL, et al. Comparison of rates of death having any death-certificate mention of heart, kidney, or liver disease among persons diagnosed with HIV infection with those in the general US population, 2009–2011. Open AIDS J 2015;9:14–22. [7] Quinones A, Lobach I, Maduro Jr GA, Smilowitz NR, Reynolds HR. Diabetes and ischemic heart disease death in people age 25–54: A multiple-cause-of-death analysis based on over 400,000 deaths from 1990 to 2008 in New York city. Clin Cardiol 2015;38(2):114–20. [8] GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385(9963):117–71.
Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Assigning appropriate primary cause of death and indication for medical procedures Nnabuike Chibuoke Ngene a,b,⇑, Jagidesa Moodley c a
Department of Obstetrics and Gynaecology, Edendale Hospital, Pietermaritzburg, South Africa University of KwaZulu-Natal, Durban, South Africa c Women’s Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa b
a r t i c l e
i n f o
Article history: Received 6 March 2015 Accepted 3 April 2015
a b s t r a c t The most appropriate primary cause of death in a patient who had multiple medical conditions is that medical condition which initiated the chain of events that led to the other medical conditions that resulted in death. In clinical practice, there are deceased patients who had several medical conditions that could lead to death (primary causes of death) without biological plausibility that any of the medical conditions initiated the chain of events that resulted in the other medical conditions. To assign the single most appropriate primary cause of death to such a deceased patient is challenging. Under such circumstances, the International classification of diseases and related health problems, tenth revision (ICD-10) guidelines recommend that the medical practitioner certifying the death should decide on the primary cause to be assigned. The ICD-10 also acknowledges that the recommendation is arbitrary. Similar difficulty is also encountered when a single indication is being assigned to a patient for a medical procedure when there are multiple indications for such a procedure. The ICD-10 and its clinical modification (ICD-10-CM) which provides the guidelines for assigning indication for a medical procedure use criteria that are insufficient. In the present article, comprehensive, easy and objective clinicopathological criteria on how to assign the single most appropriate primary cause of death or indication for a medical procedure are recommended. The new criteria (referred to NJ model II) may be used to improve the ICD-10. Ó 2015 Elsevier Ltd. All rights reserved.
Introduction It is challenging to assign one primary cause of death to a deceased patient who had multiple principal diagnoses. Similar difficulty is encountered when a single indication for a medical procedure is being assigned to a patient who has multiple reasons to undergo such a procedure. The International classification of diseases and related health problems, tenth revision (ICD-10) guidelines devised to address these challenges is inadequate [1] and, therefore, needs to be improved. The present article posits novel solutions to these challenges. ICD-10 recommends that if a deceased patient had multiple primary causes of death, the medical condition that could have led to other primary causes of death should be selected when a single most appropriate primary cause of death is to be chosen [1]. However, where the general principle is not applicable, the death certifier (if possible) should provide clarification on what could be selected as the single most appropriate primary cause of death. ⇑ Corresponding author at: P.O. Box 101894, Scottsville, Pietermaritzburg 3209, South Africa. Tel.: +27 83 518 7391; fax: +27 86 613 9560. E-mail address: [email protected] (N.C. Ngene). http://dx.doi.org/10.1016/j.mehy.2015.04.002 0306-9877/Ó 2015 Elsevier Ltd. All rights reserved.
This is because the selection rules are somewhat arbitrary and could lead to an unsatisfactory selection of the underlying cause [1]. The development of novel criteria proposed in the present article is an attempt to resolve this limitation of ICD-10. Furthermore, both ICD-10 and its clinical modification (ICD-10CM) [2] do not provide sufficient guidelines on how to select the single most appropriate indication for a medical procedure when a patient has multiple indications for such a procedure. For instance, the ICD-10-CM recommends that the medical condition chiefly responsible for the therapeutic services being provided to a patient should be selected as the first indication for a medical procedure offered to such a patient [2]. However, the criteria recommended in ICD-10-CM for the selection of the medical condition that is chiefly responsible is subjective [3].
The hypothesis Our hypothesis is that the use of novel criteria (proposed in the present article) to assign the most appropriate single primary cause of death or an indication for medical procedure will yield more reproducible results (primary cause of death/an indication)
80
N.C. Ngene, J. Moodley / Medical Hypotheses 85 (2015) 79–81
than ICD-I0 or ICD-10-CM. The novel criteria are referred to as NJ model II for easy referencing. The criteria in NJ model II are comprehensive and not subjective unlike those of ICD-10 that are occasionally arbitrary/insufficient. NJ model II is an idea that has evolved following the previously published NJ model that entails the use of clinicopathological criteria to assign principal diagnosis [3]. NJ model II 1. Assigning an appropriate primary cause of death: if a patient has multiple primary causes of death and there is no single cause of death/medical condition that possibly could have led to the other primary causes of death, then the medical condition with the highest local case-fatality rate should be selected as the most appropriate primary cause of death. 2. Assigning an appropriate indication for medical procedure: when a patient has indications to undergo a medical procedure, the single most appropriate indication for the medical procedure is that which first satisfies the top-most criteria described below: (a) Absolute indication that occurred first. (b) Absolute indication that prevents the use of other available treatment modality with the best efficacy. This is applicable where multiple absolute indications exist and their order of occurrence is not known. (c) Absolute indication with the highest local case fatality rate. This applies to a situation where the order of occurrence of absolute indications is not known, and the existing indications do not prevent the use of other treatment modality, i.e. does not satisfy criterion 2b. (d) Absolute indication. This is obtainable when there is only a single absolute indication with or without any relative indication. (e) Relative indication that prevents the use of available alternative treatment modality with the best efficacy. This criterion is important where there is no absolute indication but existence of multiple relative indications. Given that relative indication does not mandatorily require that the medical procedure is performed, in authors’ opinion, the order of occurrence of relative indication is not of priority. For instance, in an empirical case report, a primigravida at term was diagnosed with prolonged latent labour after a ruptured membrane. She subsequently developed a suspicious cardiotocography and had a caesarean section (CS). The indication for the CS is fetal compromise and not prolonged latent labour because the suspicious cardiotocography prevented the use of oxytocin for augmentation of labour. Either the prolonged latent labour or suspicious cardiotocography is a relative indication for CS. This case report is described in greater details under empirical data. (f) Relative indication associated with the highest local case fatality rate. Evaluation of the hypothesis The use of simple comprehensive and objective criteria (NJ model II) proposed in the present article will reduce subjectivity, and ensure that a reproducible primary cause of death or indication for a medical procedure is assigned to each patient. This is the strength of NJ model II. It is acknowledged in the ICD-10 that the guidelines on how to assign the most appropriate single primary cause of death prescribed in the ICD-10 are arbitrary [1]. The arbitrary rule may partly explain the 45.5% mean discrepancy rate between the causes of deaths assigned clinically and the histopathological autopsy findings [4]. Although variations have
been noted in autopsy reports, [5] histopathological autopsy, in particular, is considered the gold standard for confirming the cause of death [4]. When two autopsies performed on the same individual shows discrepant reports (primary cause of death), a third autopsy should be considered. If a third autopsy is not possible, NJ model II may be applied and the condition with the highest case fatality rate selected as the most appropriate cause of death. Nonetheless, the difficulty of determining case fatality rates is a limitation that may be associated with the use of NJ model II. In the authors’ opinion, case fatality rate is an objective criterion, and its use is, therefore, appropriate. Causes of death in patients with several medical conditions have been reported in the literature [6–8]. In such reports, the use of case fatality rates, as recommended in NJ model II, may be of value in guiding the selection of the most appropriate cause of death. To test the NJ model II, a cohort of selected patients will be assigned the outcome of interest (primary cause of death or indication for medical procedure) by a group of medical practitioners using ICD-10 guidelines. Another group of medical practitioners will use NJ model II to assign the outcome of interest to the same cohort of patients. The proportions of reproducible outcomes assigned by each group of medical practitioners will show the superiority/inferiority of NJ model to ICD-10. Plans are underway to employ the proposed method to evaluate NJ model II. Empirical data In an empirical case report, a primigravida at term was diagnosed with prolonged latent labour after a ruptured membrane. She subsequently developed a suspicious cardiotocography and had a caesarean section (CS). The patient had no co-morbidity, and both the CS as well as the postpartum period was uncomplicated. The attending medical officer was requested to select an indication for each CS performed in that hospital. While compiling the list of the indications, the same attending medical practitioner selected prolonged latent labour as the indication for the CS performed on the primigravida. The medical practitioner was of the opinion that either fetal compromise or prolonged labour could be selected, that the choice is at the medical practitioner’s discretion. We argue that practitioner’s choice should be guided by criteria that are apt to generating reproducible result. ‘‘Based on NJ model II (criterion 2e), the most appropriate indication for the CS should be fetal compromise and not prolonged latent labour. This is because the suspicious cardiotocography, a possible evidence of fetal compromise, influenced the management decision not to use oxytocin to augment the labour. Fetal scalp pH testing that helps to establish fetal compromise is not recommended in our centre due to high incidence of Human Immunodeficiency Virus infection. Either the prolonged latent labour or suspicious cardiotocography is a relative indication for CS. Consequences of the hypothesis The use of NJ model II will ensure that a reproducible primary cause of death and or indication for a medical procedure is assigned to each patient. The frequency of such primary causes of deaths or indications for medical procedures is of public health importance and may influence health policies. Sources of support in the form of grant None. Conflict of interest statement The authors have no conflicts of interest to declare.
N.C. Ngene, J. Moodley / Medical Hypotheses 85 (2015) 79–81
References [1] World Health Organization. International statistical classification of diseases and related health problems. 10th Revision, vol. 2 instruction manual. 2010 edition. Geneva, Switzerland. Available at:
81
performed on victims of traumatic asphyxia in a mass disaster. J Forensic Leg Med 2014;22:33–6. [6] Whiteside YO, Selik R, An Q, Huang T, Karch D, Hernandez AL, et al. Comparison of rates of death having any death-certificate mention of heart, kidney, or liver disease among persons diagnosed with HIV infection with those in the general US population, 2009–2011. Open AIDS J 2015;9:14–22. [7] Quinones A, Lobach I, Maduro Jr GA, Smilowitz NR, Reynolds HR. Diabetes and ischemic heart disease death in people age 25–54: A multiple-cause-of-death analysis based on over 400,000 deaths from 1990 to 2008 in New York city. Clin Cardiol 2015;38(2):114–20. [8] GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385(9963):117–71.